© 2009 The Medical-Legal News
By Frances W. Sills, RN, MSN, ARNP
The increasing acuity of patients, development of new technologies, and the increasing expectation along with the responsibility for today’s nurses to be competent in the area of physical assessment has presented new challenges for the nursing profession.
The ANA Standards of Nursing Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process.
The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation and evaluation. The first standard clearly states: “The registered nurse collects comprehensive data pertinent to the patient’s health or the situation.”
The measurement criteria for this standard are as follows:
• The nurse collects data in a systematic, ongoing process.
• Involves the patient, family, other healthcare providers, and environment, as appropriate, in holistic data collection.
• Prioritizes data collection activities based on the patient’s immediate condition or anticipated needs of the patient or situation.
• Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data.
• Uses analytical models and problem-solving tools.
• Synthesizes available data, information and knowledge relevant to the situation to identify pattern and variances.
• Documents relevant data in a retrievable format.
It is important for every registered nurse to remember that the standards of nursing practice are authoritative statements by which the profession describes the responsibilities for which its practitioners are accountable.
While the standards reflect the values and priorities of the profession, they also provide direction for professional practice and a framework for the evaluation of this practice. They define the nursing profession’s accountability to the public and the outcomes for which the registered nurse is responsible.
Each time I review a medical record I am dismayed at the lack of data, incomplete data and at times conflicting data found in the nursing admission assessment and other assessment tools that are used for special concerns such as assessments specific to skin, risk for falls, activities of daily living and cognitive function, etc., just to mention a few.
The purpose of this continuing educational offering is to present two standard assessment tools used to assess cognitive functioning in adults, what they are, why they are administered, and what the findings mean.
At the completion of this CE, the participant will be able to explain the components, the scoring and the significance of the two tools: the Short Portable Mental Status Questionnaire (SPMSQ) and the executive functioning exam (which contains three tests that involve drawing, spelling and counting).
A number of frameworks are available that address neuropsychological function, specifically those in the area of executive function. Executive function “involves the ability to think abstractly and to plan, initiate, sequence, monitor and stop complex behavior, according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Conney and colleagues describe executive function similarly as “an interrelated set of abilities that includes cognitive flexibility, concept formation and self-monitoring.” Assessing executive function can help determine a patient’s capacity to execute healthcare decisions and discharge planning decisions.
Short Portable Mental Status Questionnaire (SPMSQ)
The SPMSQ consists of 10 questions testing remote memory, awareness of current events and mathematical ability. It is part of the Older Adults Resources and Services instrument (OARS) and has been used extensively with the older adult. Each error is scored as 1 point, with intact mental function indicated by less than two errors and severe impairment indicated by eight to 10 errors. The questions asked are:
• What is the date today?
• What day of the week is it?
• What is the name of this place?
• What is your telephone number?
• What is your street address? (Ask only if the patient does not have a telephone).
• How old are you?
• When were you born?
• Who is the president of the U.S. now?
• Who was the president just before him?
• What was your mother’s maiden name?
• Subtract 3 from 20 and keep subtracting 3 from each new number, all the way down.
• 0-2 errors=intact mental function.
• 3-4 errors=mild intellectual impairment.
• 5-7 errors=moderate intellectual impairment.
• 8-10 errors=severe intellectual impairment.
• Allow one more error if the subject had only a grade school education.
• Allow one fewer error if subject has had education beyond high school.
While the SPMSQ can provide evidence of possible intellectual impairment, which in itself will provide the healthcare providers valuable information as they develop the individualized treatment plan, it does not provide information regarding executive cognitive dysfunction. Studies have suggested that dysfunction of the executive cognitive skills can more reliably predict loss of autonomy than memory impairment can. Executive cognitive function allows for abstract thought, the planning of, and taking of, actions toward a goal and adaptation to the unexpected. With executive function and memory operating in distinct regions of the brain, the patient can suffer executive dysfunction even when memory is not impaired.
The importance of screening for executive dysfunction cannot be over emphasized. While impairment of executive function is associated with the various dementias, it has been found that it may occur even when dementia is not thought to be present or when memory appears to be intact. You may see a patient who can do very well with the SPMSQ or the Mini Mental Exam and not do well when the executive cognitive functions are tested.
Whether or not memory is impaired, executive dysfunction can affect one’s ability to carry out activities of daily living, independent activities and the ability to direct one’s caregivers. The detection of this dysfunction is critical to a patient’s safety and independence.
Neuropsychological studies have suggested that executive dysfunction may more reliably predict loss of autonomy than memory impairment will.
Three brief tests for executive dysfunction allow for early detection. It is important to know that cognitive testing requires sensitivity. Patients react differently when such testing is suggested. Regardless of whether cognitive deficits exist or not, a non-threatening approach can help to decrease anxiety and permit assessment.
The three screening tests of executive function
Royall’s CLOX clock drawing
• Part one: First ask the patient to “Draw me a clock that says 1:45. Set the hands and numbers on the face so that a child could read them. Once the task is complete, draw a clock with a 2 inch diameter, with all the numbers in place, and the hands set at 1:45.”
• Part two: Then ask the patient to copy it. An unimpaired person will draw a round figure with the following elements: recognizable circle at least one inch in circumference with all the numbers present and in correct, symmetrical sequence. There will be two hands anchored in the center pointing to the correct time. If any of the above elements are missing the person is possibly impaired. If more than one element is missing the person is probably impaired. Intruding elements such as words or letters indicate impairment.
Persons with only executive dysfunction will exhibit errors on the first clock but not the second. Those with both executive function and construction apraxia, usually as a result of moderate Alzheimer’s disease or stroke, will fail both.
The Controlled Oral Word Association Test
With categories beginning with letter “F,” then “A” then “S,” the Controlled Oral Word Association Test by Spree and Benton (1977) requires the respondents to fill in the category by providing words of three or more letters. For example, correct responses to the category cue “F” would include “fish, foul, fact,” etc. This test reflects abstract mental operation related to problem solving, sequencing, resisting distractions, intrusions and perseverations. It is considered a “frontal” task as the organization of works by first letter is unfamiliar, and requires conscious, effortful, systematic organization and the filtering of irrelevant information such as natural taxonomic categories. Persons free of executive dysfunction will produce 10 words in each category within one minute. For a person with at least a high school education, a total score of 30 or more points indicates no impairment.
The Trail Making Test, Oral Version (Ricker& Axelrod)
This test requires the subject to count from 1-25 and then recite the 26 letters of the alphabet. The subject is asked to pair numbers with letters in sequence, e.g. “1-A, 2-B, 3-C,” etc., until the pair “13-M” is reached. This version does not make visual scanning or visually guided motor demands. However, the individual is required to keep the number and letter sequences in working memory so as not to lose place. More than two errors in 13 pairings is considered impairment.
It is important to remember that the complex nature of executive function, including its interdependence on other domains such as memory and communication, make it difficult to determine the actual presence of dysfunction with certainty. The criteria for finding executive dysfunction are now emerging in clinical practice.
For legal nurse consultants or healthcare attorneys, this provides yet another avenue to assess the appropriateness of patient care plans, treatment plans or discharge planning.
This brief evaluation of executive dysfunction is particularly useful in patients not thought to have some type of dementia or confusion prior to the hospitalization, but the patient, family or staff feel that he or she has not returned to prior baseline cognitive status at the time of discharge. These three screening tests can provide information that will result in a much safer and more realistic treatment and discharge plan. •
Frances W. (Billie) Sills, RN, MSN, ARNP, is an assistant professor at ETSU College of Nursing in Tennessee;firstname.lastname@example.org.
Find the CE answer sheet on the next page.